There are fewer areas in this information age where one finds more unidentified concerns than trekking, especially when it comes to High Altitude trekking. Have seen friends looking at their fingers in snow getting a bit pale and starting to fear Frost bite! Many a times you would have observed someone panicking over his / her fingertip going a bit numb and everyone else in the groups giving their own hunches of whether it can be Frost bite or not. Sunburn and SPF are other interesting topics that people offer many interpretations for. And not to forget Snow blindness, I think many trekkers don’t even realize that this is an illness for sure and I have seen people taking the sunglasses requirement a bit casually when the illness can be quite severe and damage your eyes significantly.
The purpose of this article is to initiate an informed discussion on some of the topics related to Mountain illnesses (or high altitude illnesses) and recognize simple yet effective measures to solve or prevent such problems. I am no doctor or high altitude expert and hence there is no risk of this article going overboard. In fact, I would leave some open questions in this article where some of you may add answers and tips learned by experience or otherwise.
Mountain & High Altitude
So let us start from the beginning, what can be said as Mountain and High Altitude areas. Well the two are quite different. Indian subcontinent is blessed with many mountain ranges like Aravalis (oldest), Nilgiris, Satpura, Himalaya, etc. But not all of them offer High Altitude treks. Most of high altitude trekking in India happens in Himalayas with a few exceptions in Nilgiris and certain others. So then how do we define High Altitude. Well the experts tell us that any altitude above 8000 to 9000 ft would be classified as high altitude area. But actually to me what is more relevant is the “Why”. Why do we actually need to define High Altitude areas? Well the reason is Oxygen! You all know that air pressure decreases as we move up the surface of earth of Sea level as can be established as a formal reference point. So if you are livng in Mumbai and you move to Uttarkashi, you have already moved 4300 ft above the sea level and the air pressure has dropped by around 130 mb. The drop in air pressure means that the air is going thinner (the density of air molecules is lesser due to lower gravity effect). Contrary to popular belief, what is lesser at higher altitude is not just Oxygen but all gases, in fact the air itself. However, what matters the most to us, humans and animals (have seen dogs also start trekking these days) is the lack of Oxygen levels compared to normal sea level and hence we need to define High Altitude areas for us to be able to plan our health better in such areas.
Why do I need to understand what is High Altitude?
Now that we have understood the expert definition of High Altitude, let’s see how does it matter to us? Now, any definition by experts, as you would know, comes with caveats. So here is the caveat for this definition: “High Altitude impact is a relative phenomenon, please apply your context and judgement before taking any actions” (sounds like “Market investments are subject to market risks...” doesn’t it?). So what does this mean? Where do we now go and read our context? Will Google tell us? Well let’s take a small story here: A mountaineering team was waiting at Everest Base camp for their turn to ascend and acclimatizing their bodies in the meantime. One evening he saw 3-4 children of Sherpas running around at the base camp playing a local version of football. While the whole team there was struggling to walk with normal breathing, these children were running for hours without any problem. Next day, the team heard of a child born at the base camp and were amazed (despite knowing the reasons scientifically) by the diversity of human body. So what was different about those children playing at base camp and that child born there? The Context or Red Blood Cell count (simply speaking). RBC is the main carrier of oxygen in your body and what can compensate for lower levels of oxygen in the environment is the higher count of RBC. Typically the people living in higher regions have higher RBC through evolution and hence do not feel similar problems at high altitude as some others living in the plains. You can formally get your RBC tested for record if you are very particular but if not, knowing the fact that RBC count can be increased by your body as required should help. This process of your body increasing the RBC and preparing certain other hormones for you to become comfortable at High Altitude is called acclimatization. We shall discuss the process of acclimation in another article but let’s just understand that this process can make your body ready to live or climb in High Altitude areas. This process of acclimatization is the reason why we should understand the meaning of high altitude.
Illnesses in Mountain
The illnesses in the mountain can be classified on different parameters but we shall classify in very simple terms that can be remembered:
1. Illnesses due to heat or exhaustion 2. Illnesses due to extreme cold conditions 3. Illnesses due to High Altitude
As I mentioned earlier, high altitude areas are not relevant for many trekking regions except Himalayas or some other ranges like Alps in the world. However, since trekking is an endurance field, so exhaustion illness are relevant across. Also, many treks or even other adventure expeditions like cycling etc. can be through very cold regions or snow laden regions without being classified as “High Altitude”. So let’s see them one by one.
1. Illnesses due to Exhaustion or heat
a. Dehydration – I am not sure whether this can technically be qualified as an illness but this is the most important problem that trekkers face. Its not necessary that one gets dehydrated only in the high temperatures of Indian plains, one can be dehydrated in the lower or even upper Himalayan regions as well. The problem arises from an imbalance caused between fluids consumed and lost by the body. Since the human body is mostly water, this is the easiest imbalance to start causing problems for the body. Cramps in muscles, pain, tiredness, are symptoms that can alert you for dehydration. Simplest prevention is water intake. Drink plenty of water while hiking (as much as you want and afford) and this is applicable at all altitudes, all temperatures, all terrains. Water intake protects you not just from dehydration but also many other problems that we would see later. But what if you don’t have access to that much water while hiking? In such cases, you can try some additives like Glucose, Electral, ORS solution, or even simple salt. Take frequent rest under shades and walk at a pace that is suitable to your body. Don’t try and match someone else’ pace to exhaust yourself with perspiration. Conservation of energy would help in losing less fluid.
b. Heat Exhaustion – This is nothing but an advanced stage of dehydration. The symptoms are (in addition to dehydration) cramps in abdomen, pale skin, breathlessness. The person suffering must be given rest under shade and provided with Glucose or Electral solution.
c. Heat Stroke – This is an extreme situation where the person has been dehydrated for long time. The person would stop sweating and develop an abnormal pulse ( can be very rapid) along with confused state of mind and extremely dry skin. The person must be rushed for medical help immediately after providing fluids as described earlier. Preferably, the person should be carried by others or moved very cautiously otherwise.
2. Illnesses due to Snow or Low temperatures
a. Cold Injuries – Chilblain, Frostbite, Metal bites – Cold injuries are (as is evident!) caused due to exposure to sub-zero temperatures. Our body parts and especially skin are not used to handling such low temperatures at a regular basis. The body parts that are impacted the most by cold injuries are Fingers, Toes, Ear Lobes, Nose, Cheek, and Buttocks because they have the maximum probability of exposure to cold. Lets discuss the above mentioned injures one by one:
i. Chilblain – this is a condition in which the capillary beds in the skin are damaged. Finger tips and toe tips if exposed to snow or very cold water are susceptible. Red / pale skin, itching, swelling, and reduced sensation are some of the symptoms of chilblain. While this is not a very serious illness but if ignored, can grow more serious and damage the affected part permanently. If affected, one should re-warm the affected part as soon as possible but the process should be slow. Don’t try to put the hands in fire because it won’t help! Use dry and warm gloves or clothes to re-warm. If the condition does not improve or the pain grows, one can take a pain killer as well.
ii. Frostbite (1st Degree) – Frostbite is one of the most dreaded illnesses in the field of trekking and mountaineering. This condition is more dreaded and less understood. I have heard many trekkers looking at their numb fingers and thinking that it might be frostbite. So let’s understand why is it dreaded? The condition occurs in 4 degrees and deteriorates quite fast. It starts with 1st degree where the symptoms are similar to Chilblain which is why it becomes a bit difficult to distinguish between the two. 1st degree Frostbite is completely reversible and the only way one can distinguish between this and Chilblain is the pain which is much stronger in Frostbite. Rest of the symptoms are same as Chilblain. The good thing however is that the treatment is the same and re-warming alone can reverse the process back to normal.
iii. 2nd Degree - When the exposure is higher, Frostbite can grow to 2nd Degree in which the affected part develops evident blisters that are pink in colour. From this condition onwards, one needs medical attention as soon as possible. Injections for Tetanus and Antibiotics are required.
iv. 3rd Degree – When the blisters deteriorate further and turns blue or pale blackish and the loss of skin turns permanent, the symptoms are that of 3rd degree Frostbite. With urgent medical attention that can include surgery or grafting, the organs can be saved that can recover with physiotherapy.
v. 4th Degree – This would typically happen when you are stuck without resources in the mountains for many days together. The organs affected are unfortunately not recoverable and the symptoms are completely dead, painless areas appearing completely black. Amputation is the only way to stop further growth and damage. Well before you get scared, let me just draw a reference. When you are stuck in an adverse situation in the mountains without resources, chances are that you have survived an avalanche or storm or something similar that was an accident. A life saved would always have one notch higher priority compared to any other loss in this world.
vi. Metal bite – This can happen when you touch any metal equipment or items at very low temperatures with naked hands or any other part of the body. Typically the equipment that hurt us are Ice Axe, utensils or sometimes pitons that we try to hold with our teeth when stranded on an ice wall. Sometimes a full layer of skin can get removed if contacted with a very cold metal body. Always use your gloves before holding your metallic equipment to prevent this.
Everyone knows that precaution is better than cure but sometimes our laziness can make us forget anything. Gloves, shoes, warm and dry clothes in the rucksack are your lifeline in the mountains. Don’t leave them behind and use them with anchors. Frostbite or Metal bite is completely avoidable and in recent past, with the advent of good quality gloves and shoes, the incidents have reduced drastically.
b. Snow Blindness – this is caused due to one’s eyes getting exposed to excessive radiation. A very simple precaution of wearing dark shades in snow, if ignored, can turn into a very serious illness. The blindness is very painful and is accompanied with continuous water running down one’s eyes. Snow absorbs only about 25% of the light falling on its surface compared to almost 95% absorbed by a dense forest and hence the excessive radiation looking into snow can damage the capillaries in the eyes. Mostly recoverable, the condition can damage the eyes permanently if ignored continuously for more than 3/4 days.
c. Sun Burn – this is the damage caused to skin due UV radiation exposure. As explained above, snow reflects back almost 75% radiation falling on its surface that contains UV rays higher in similar proportion. Best precaution, contrary to popular belief is not Sunscreen cream, is to cover as much as possible the body parts. Wear full T-Shirts covering your arms, a well rounded hat, and a scarf covering your face & neck. If not possible, then sunscreen can be used. When we talk about sunscreen, one point that is not commonly understood is “SPF”. SPF stands for sun protection factor but the full form sadly does not always explain what the hell it is! SPF is a logarithmic scale that defines the extent to which the sun rays would be reflected by a layer covered with sunscreen. An SPF rating of 15 means that 93% of the radiation would be reflected back and only 7% would be absorbed, SPF 30 reflects 97% and SPF 50 reflects 98%. For continuous snow exposure, any sunscreen with SPF rating of 50+ is recommended. The biggest limitation of sunscreen is the fact that while trekking its almost impossible to ensure that a proper layer exists on the skin exposed. With all the perspiration that takes place while trekking, the sunscreen keeps flowing away and one has to keep reapplying the cream every now and then depending upon the extent of perspiration one experiences.
d. Hypothermia – An extreme condition that is often loosely referred to in the field of trekking by any terrified trekker feeling cold or wet. Hypothermia happens due to continued exposure to cold conditions and results in the body temperature falling below normal (37*C) can be classified into 3 stages :
i. Mild – When the temperature falls and is in the range of 35 to 32*C. Extreme shivering accompanied with slight memory loss, difficulty in speaking, and problems in swallowing are the prominent symptoms.
ii. Moderate – When the temperature falls in the range of 32 to 28*C. Stiffness in the body, Shallow breathing, and abnormal blood pressure are some of the symptoms in addition to the ones listed above.
iii. Severe – When temperature falls even below 28*C. The affected person can go into Coma and this can even lead to death.
Rest is immediately required in such condition along with fluids having high sugar levels. Remove all wet clothes and drape the affected person in as much warm clothes as required.
3. Illnesses due to High Altitude
a. Acute Mountain Sickness (AMS) – The cause of any high altitude sickness is basically improper acclimatization that leads to an imbalance in the body. The condition is many a times aggravated due to undue exertion or an unreasonable ascend (more than 12 hours in a day) or even alcohol. Symptoms of AMS are headache, nausea or even vomiting, loss of sleep, loss of appetite, fever, weakness, dizziness, and memory loss. The problem with AMS is that we don’t often realize that it is AMS! So the golden rule mostly offered is “Whenever in doubt at high altitude, assume its AMS”. The first step if you feel such issues is to consume as much fluid as possible and stop further ascent if possible. Its normal for anyone to feel these symptoms and your body is very well equipped to handle them. Whenever you stop at a high altitude camp, always camp at a lower altitude than what you gained during the day. One can always go for a altitude gain walk before camping. Be active and don’t sleep when you reach high altitude area. If the situation does not improve within a few hours, 250 mg dosage of Diamox (thrice a day) can be consumed for short term relief.
b. High Altitude pulmonary Oedema (HAPO) – Another often heard of but less understood term. HAPO is a condition that is preceded by AMS or AMS if further deteriorates, can turn into HAPO. It affects one’s lungs and what basically happens is accumulation of fluids in the lungs. Symptoms are the same as AMS but accompanied with some others that can indicate further worsening of AMS. These unique symptoms are Breathlessness, Abnormal pulse, and blood in sputum. The condition demands immediate descend which is actually the best treatment. Tab. Nifidipine (20mg) can also be given in addition to Diamox (250 mg). HAPO bag can offer a good but only temporary rescue from HAPO. A HAPO bag basically increases air pressure inside the bag and hence makes one feel as if the pressure altitude has decreased. HAPO bag is no treatment for HAPO however. It only offers temporary relief and stops further deterioration. It does not have any side effects either.
c. High Altitude Cerebral Oedema (HACO) – while the starting point of both HAPO and HACO are same i.e. deterioration of AMS but the conditions are very different. HACO is related to brain and it basically affects the functioning of brain. The symptoms are altered walk, double vision, seizure / fits, irritability, and drowsiness. Immediate descend most effective treatment here again. Dexamethasone (4mg) can be given in addition to Diamox (250mg).
d. High Altitude Systemic Oedema (HASO) – this is a less heard of illness usually more apparent in women. Swelling in feet, hands, and face are the typical symptoms of HASO and is usually seen in the morning. One should avoid tight clothes and reduce the consumption of salt for relief.
All these illnesses except the ones caused by high altitude are mostly caused by some ignorance or negligence or accident. We can’t do anything about an accident but can definitely be more careful and avoid any negligence on mountains. As I said in the beginning the purpose of this article is to initiate a discussion on Illnesses in the mountains and common treatments that can be administered by any common trekker. I hope the article would help you understand better about the reasons of the illnesses caused in the mountains and offer some tricks to avoid them. Wish you happy and safe trekking.
Note : We have prescribed a few medicines as per the standard routines followed in the field of mountaineering. You are advised to consult your doctor for any specific medical condition or allergy that you may have.